Physical Diagnosis, M2 Course

Musculoskeletal/Extremities

Devin Nickol, M.D.

OBJECTIVES

Following today's lecture, students should understand the following:

     1. The scope and importance of back pain as a medical problem.

     2. The common causes of back pain, and techniques used in their diagnosis.

     3. A rational approach to the treatment of patients with back pain.

 

CASE PRESENTATION

     A 32-year old male presents to clinic with a complaint of low back pain. He was in his usual state of good health until three days ago when he spent approximately 45 minutes shoveling snow. Later that evening he noted the onset of gradually worsening low back pain which made it difficult to sleep. He tried taking over-the-counter ibuprofen with only minimal relief. For the last two days the pain has been so severe that he has stayed home from work. He states, “I can’t get off the couch.”

 

BACK PAIN: WHAT CAUSES IT?

- Think about the anatomy: where are pain fibers found?

 

 

- What sorts of things can go wrong with those structures to cause pain?

     Bones:

 

 

     Ligaments, muscles and fascia:

 

 

     Intervertebral discs:

 

 

     Spinal nerves:

 

 

- How common are various causes of back pain?

 

 

HOW SHOULD YOU EVALUATE A PATIENT WITH BACK PAIN?

- What basic steps should you use in approaching a patient with back pain?

 

- What history elements are important in ruling out cancer or other significant systemic disease?

 

- What four things can you ask to essentially rule out cancer?

 

- How can you rule out surgically significant lumbar disc herniation?

 

- How can you rule out cauda equina syndrome?

 

- What is the role of the physical exam?

 

- What is the role of imaging studies?

 

HOW SHOULD YOU TREAT A PATIENT WITH BACK PAIN?

- What if they have a symptomatically herniated lumbar disc?

 

 

- What if they have spinal stenosis?

 

 

- What if they have chronic low back pain of uncertain etiology?

 

 

- What if they have acute, nonspecific low back pain?

 

 

- What is the natural history of untreated back pain?

 

 

CASE PRESENTATION

- Consider the gentleman in the previous case presentation: what else do you want to ask him?

 

- What sort of exam would you like to perform?

 

- What diagnostic tests would you like to order?

 

- What is your differential diagnosis?

 

- What should you do for this patient?

 

- What should you tell him about his prognosis?

 

 

 

BIBLIOGRAPHY/FURTHER READING

Back Pain Guru: Richard A. Deyo, M.D., M.P.H.

 

“Low Back Pain” NEJM 2/1/2001: 363-369

“What Can the History and Physical Examination Tell Us About Low Back Pain?” JAMA 8/12/1992: 760-765